Question about Family Physician Shortage

[Guest Macmeds06]

Hi everyone,

 

I just finished reading an article from the College of Family Physicians website about the declining numbers of students choosing Family Medicine in the Carms. (www.cfpc.ca/English/cfpc/...t.asp?s=1)

 

They mentioned the already well known statistic that many family docs are working 70+ hour workweeks, contributing to the negative lifestyle image many medical students perceive about the field. My question is this: Is there anything to stop an FP (especially a new graduate) from capping his/her patient volume at a lower number and working a more reasonable schedule (say 50 hours a week)? Obviously one would expect a lower income level, but is this idea unreasonable?

 

Aside from altrusim and serving the community, or trying to obtain a greater income, is there anything forcing these doctors to break their backs with the 70+ hour workweeks? (Is there something in the job description I'm not aware of?)

 

Thanks in advance

[Guest aneliz]

Well, you could cap your patient volume at a lower level and work more 'reasonable hours' but the obstacles to this are the following:

 

1. The shortage of specialists and hospital resources mean that patients are waiting ridiculous amounts of time for referrals (12 months+ in some cases) and for diagnostic tests like MRI's. There are huge waits for surgery, cancer treatment, etc, etc. There are also huge deficiencies in rehab care and long term care (nursing home) beds. And people are being discharged from hospital faster than ever. What does all this mean? Well, all of these problems land directly in the family physician's lap. It is the family physician that has to try to speed up the process for patients, that has to try and manage complex medical issues that should be dealt with by a specialist in the area until the patient can get an appointment with a specialist. It is the family phyisican that has to try and problem solve with the family to support very ill people that are at home with relatives after being discharged from hospital or while waiting for long term care. It is the family physician that has to deal with getting home care, and dealing with school systems, and social services, etc. All of these things take an immense amount of time given the lack of resources in almost every area and the increased level of need from the patients...so even if you limit the number of patients, it can be difficult to limit the amount of time.

 

2. If you limit the number of patients in your practice, you may be able to work more 'reasonable' hours....but if you do this, like you said, you limit your income. The cost of operating a family practice is HUGE...remember that you pay staff, overhead expenses like rent, hydro, insurance, computer and office expences etc from your billings, so your billings do not equal your salary... and these are somewhat fixed costs...they do not really change with the number of patients you see...so if you limit your patient volume, you will not only be billing less, but you will have a higher percentage of your income going to overhead. One figure quoted to us is that the current 'take home income' of most family physicians is ~$90 000...don't even want to know what it would be with less patient volume.

 

3. The biggest reason of all for new grads = DEBT.

 

When you graduate with >$125 000 in debt, it is really hard to go into a specialty that you know is going to ultimately produce less income. Family doctors used to make ~80% of what a specialist did, now they make ~60% of what specialists do. And remember that you are going to have to borrow even more money to set up a family practice or buy an existing one...and then you need things like a house and a car too....and you need to save for your retirement, because there's no pension or benefits coming!

 

 

4. Attitude towards family medicine presented by medical schools

 

I personally have found that family medicine is presented in a very negative light to students. We are taught almost exclusively by specialists...we rarely see any family docs...and the ones we do see, go to great lengths to tell us how 'burned out they are' and how much 'family medicine sucks' and all of the problems that they face. I have yet to hear a family doc tell me that they really enjoy what they are doing...instead we hear about how the government is screwing them, how many hours they put in, how miserable their working conditions are, their frustrations with staff, the system, dealing with patients that are on perpetual waiting lists...because it is the family docs that get to deal with most of family and patient frustrations with the health care system...

 

And, we have specialists that have made comments like "and then the patient was referred to a real doctor (a specialist) and was diagnosed with X" or "and after the family doctor screwed up by doing X, the patient was finally referred to..." or "family doctors don't have a clue about X, so they usually do Y and make it worse...." And then there are the patients that complain that "my family doctor doesn't know anything...." or "my family doctor screwed up by doing X..." when in reality, the family doc is doing the best they can to manage complex issues for 6 months + that should be referred to a specialist, but can't be because of the waiting lists to see a specialist...

 

And then there is the perceived inferiority:

 

One of the graduating students from UWO was told by a specialist that she was 'too smart to be a family doctor'...when she told him that she wanted to do family medicine.

 

So, given all of these things, where is the incentive to do family medicine?

 

There is no financial incentive, there is apparently no ''happiness" or satisfaction in the field from what we have seen, there is little positive exposure to the field during med school, there is little respect from other physicians and even from some patients... and rising student debt levels are only going to make it worse as it becomes even less financially feasible....

 

So there is my two cents.

[Guest Macmeds06]

Thanks a ton for your response aneliz!

 

That was very informative and helps me understand the issue with greater depth.

[Guest strider2004]

After having done my rotation in family medicine, I wouldn't agree with what has been said. Smaller communities have such a high demand for family docs that they are giving very nice incentives for their practices. I was at a place that offered free rent and you only had to pay for your secretary. That cuts at least 20% off your overhead. One doc I worked with had a 3000 patient load and saw about 40 patients each day. HIs practice was well established and he chose that many patients because he could handle it. Most of them were minor assessments and only took five minutes.

Another doc had a patient load of 1400 and she stopped taking more. Why? Lifestyle. She had 2 young kids and wanted to spend more time looking after them. Her practice was also quite varied and she could go out and worked with outside institutions. She also just recently stopped doing shifts in the ER.

Another doc was just recently graduated. He was working hard for his wedding and he said he could go up to N Ontario and make $40k/mth take home by doing ER shifts and taking 1 in 3 call (which isn't unheard of in surgical specialties).

 

The final draw to family medicine (on my part) is that 'ideal' of being a doctor. If my kid came home one day with a broken wrist or ankle, would I actually know what to do or would this be my first MSK problem since med school? Specialists are so focues that they may not know how to fix common problems, which I find unattractive. Sure, a cardiologist could run a code, but could a radiologist? Family docs have enough breadth of knowledge to have the confidence to 'take a shot' at a problem. I think that is admirable.

 

As for the debt, it would make sense that a student would want to get out of debt as quickly as possible. That would be by finished training as quickly as possible and starting to work. The family medicine residency is 2-3 years shorter than any other so while one person is making $50k as an R3, a new graduated family doc could be making $200k. Which one would come out of debt first?

[Guest Shahenshah]

wow..this is a really interesting discussion with two completely opposite views..I'm a little doubtful of the 40k/month doing ER cause we're talking potentially 480k/annum..I mean that is an incredible sum and y is this not done by more people if the opportunity exists?..can someone else shed more light on that and of course continue discussing the plight of today's family docs.

[Guest Toonces]

My brother trained in family medicine and after finishing his residency a year ago, now works ER in a smallish town outside of Toronto. He received >$75,000 as a signing bonus for a 3 year contract, and because he works ER, he has no overhead. He does work lots of hours but gets a reasonable amount of time off and pulls in well over $200 K a year. And he paid his debts off in under 7 mos. And he loves it.

 

I too have heard that working in northern Ontario can be even more profitable, because the need is so much greater. The message that I get from all of this is, if you do family, have some flexibility about where you're willing to work after residency (for at least a few years), and the financial issues (i.e. debt) can be easily taken care of.

[Guest UWOMED2005]

Actually, SW Ontario has more of a physician crisis at the moment. And yes, there are a family docs who make $200k+, even $300k+ after overhead coverage incentive programs. But those are also family docs working 70-80 hrs/wk between the ER, internal medicine, and their practices. It's harder to choose your hours in a rural setting

 

In the city you can TOTALLY choose what hours you work. You are your own boss in family medicine after all! (That's something that CAN'T be said of many specialties, btw) If you don't want to work tuesday and thursday afternoons, by all means you don't have to. Heck, you don't have to work monday, tuesday, wednesday, thursday, friday, saturday or sunday if you don't want to. . . of course then your billings would be $0.

 

But if you're in a group practice where overhead is split, there is absolutely nothing stopping you from working half-weeks. That's exactly what a family doc (who just happened to sit beside me on my way to my UWO meds interview) does. She has 2 or 3 small kids and so only works a couple of mornings a week. Yeah, she's not making enough to buy 3 BMWs a year -about $60k, but how many jobs let you make $60k working part-time? And have the flexibility that you could switch incredibly easily to full-time when your kids are in full-time school?

 

I think the reasons family are less popular are fourfold:

1) Money is better in (SOME!) specialties. And the perception by many is $$ is better in specialties.

2) Respect is much better for specialists - way better. It's amazing how many times I've heard specialists (who couldn't tell the difference between a common cold and a sinusitis) knock family docs not knowing what info was presented

3) Bureacracy, paperwork, and the fact this duo tag-team often to @#%$ on family docs.

4) In order to make a practice run smoothly, you have to run it as a business first. . . makes things stressful.

[Guest aneliz]

I agree with some of the points made above...its true, if you go to a rural setting there are signing bonuses that may pay for a good chunk of your overhead and some of your debt...and lots of $$ can be made by working in an ER (especially a rural one) after doing a family med residency...but is that really doing 'family medicine' and doing anything to deal with the shortage of family doctors?....

 

And all of this assumes that you a) want to/can work in a rural setting (and for some people with family/significant other commitments, this is just not possible....) and are willing to do locums, travel a lot and work the hours of a surgical specialty (1 in 3 call) for less $$ reward

 

I would argue that it is the rare family doctor that is taking home 200+ in income.... especially in their first year out... unless of course they spend that first year working as many hours as they possibly can in incentive rich areas...

 

I agree that family docs have enough breadth of knowledge to 'take a stab at most problems' but I have also seen family doctors that just don't bother and grouch constantly that they 'can't know enough about everything to keep people happy'...and prescribe tylenol 3's to a patient with backpain rather than doing anything else (even a proper MSSK exam) because they 'don't have time' and there was 'nothing that they could do with the information anyway'....

 

I am not saying that family medicine has zero benefits...just that in my experience, it seems to have more than its share of 'negatives' at the moment....and this is not entirely the fault of family medicine as a specialty....the blame should be assigned mostly to the government (and their funding of health care, social services and education!) in my opinion.

 

To increase the popularity of family med with students, a few things need to happen:

 

1. Pay scales need to be adjusted to fairly compensate family docs for the amount of time that they put in...family medicine shouldn't be a 'second class' career to specialties

 

2. More $$ need to be invested in the rest of the health care system so that family docs don't end up dealing with patients that are in impossible and frustrating situations....(like the woman that needs a hip replacement so that she can walk and take care of her husband with dementia...but has to wait 18 months for surgery and/or 6-12 months for a nursing home bed for her husband). The surgeon doesn't deal with these problems...the family doc does....family docs often end up 'making a stab' at problems that they are really not comfortable dealing with because there is nobody else to do it or there is a ridiculous waiting time to see someone else....

 

3. More resources need to go into training/acquiring more family doctors to decrease the workload to more 'reasonable' levels.

 

4. Family medicine needs to be given more respect by other physicians and presented in a more positive light to med students...so that it is not seen as an 'inferior' choice of specialty

 

If these things were done, the problem would be solved pretty quickly in my opinion. However, it becomes a real chicken and egg problem of what to fix first and how?

[Guest Ian Wong]

Here's an old thread from earlier this year after the CaRMS match results came out (this was the worst year ever in CaRMS history with only 26% of Canadian medical graduates choosing FM as their #1 preference). Only about 15-20 years ago, that number was 50%, and that's a huge number of family doctors, and family doctor work equivalents that we've "lost" in such a short amount of time.

 

pub125.ezboard.com/fpremed101frm31.showMessage?topicID=221.topic

 

Ian

[Guest MayFlower1]

Hello everyone...although as you know...I'm not a med student (boo)...I do have some thoughts about this (Austin Powers, Goldmember).

 

The myth that you have to work unreasonable hours as an FP to make a reasonable living is determined by at least two issues: 1) what you consider to be unreasonable hours and/or 2) what you consider to be a reasonable income.

 

As I've mentioned in previous posts...too much work to find and quote them...my wife has her own practice...we have admitted almost 2000 new patients in the last 9 months or so...we have stopped taking on new patients...she works a half day on monday (i.e., 1 three hour shift monday afternoon), a full day on tuesday, wednesday and thursday (2 three hour shifts) and a half day on fridays (one three hour shift in the morning. Is this unreasonable? I don't think so... Does she work hard...absolutely...like a dog...but she does get long weekend every weekend and takes days off whenever she feels like it...just needs to give reception a few days notice to rearrange things. Oh, she also works 2 shifts a month at a local after-hour clinic (you can either give 2 shifts of time a month and make a wack of money or pay several hundred a month to have your patients seen there off hours) at an overhead rate of 20% rather than the typical 35-40%...which gives us an extra many thousand dollars a month revenue over and above 200K she brings in from our clinic....hmmmm...not bad...a bunch of work, for sure....but not a shabby living...

 

With respect to patients...we have an amazing population...we insist on co-responsibility for health...that is, the patient has a responsibility as well as the doctor...for example, we don't do reminders for appointments...you miss an appointment without an extenuating circumstance...you get a warning letter and you usually pay the regular rate, out of pocket, for the lost time slot...you miss two in a row without a reasonable excuse...you get a bill and a letter indicating we'll cover you for a month at our after hours clinic...but you had better find another family physician as we don't believe we can meet your needs...tough? A bit...but it's a docs market...why should you lose money because of someone's lack of responsibility. Anyway...that's just one of many examples. The end result is...if your practice is efficient...you do great medicine...your patients will ultimately self-select in our out...those that stay with "tough rules" are great patients...those that decide to go elsewhere (and those who are fired due to many different valid reasons) are just not in tune with your particular style of medicine. It's really up to you...could you have a horrible, complex group of patients....sure...it's easy...and don't get me wrong...everyone gets some proportion of these patients...without being unethically selecting patients for your practice...it's inevitable. That being said, I can't impress enough how much you are in control of your practice...you set it up the way you want...the patients who stay with you will align with your philosophiies and those who don't will find another, more compatible doc...

 

I hope this stirs some debate...theory is nice...but live in our shoes for a few months and you'll realize that FP is an amazing option...probably one of the best areas to specialize in...listen to the propaganda...really do your homework...look at what you want out of life (and consider that what will count at the end of the day...on your death bed...definitely won't be...I worked mega hours...had no friends or family for that matter...and made megabucks).

 

Just my two cents worth.

 

Pierre Colline (aka, Peter Hill, aka Mayflower, aka Peterhill0501)

[Guest UWOMED2005]

Pay. . . a huge part of the problem is the payscale. But an across the board fee-raise for family docs isn't warranted. The problem is there isn't enough differentiation when it comes to fees in family medicine. A family doc in Ontario gets the same $28.50 (it just went up a $1 a month or two ago) to take 5 min for a cold or sore throat. . . or 20 min to do a thorough exam on the back. . . or 30 min to properly counsel lifestyle and diet modifications to someone who has hypertentsion. No wonder some family docs are throwing tylenol #3s at back pain - they just want to get to the next sore throat so they can see enough patients to make the $150k they thought they were going to make going into medicine. If family docs actually took the time spend 30 min on counseling diet & lifestyle, most of them would go broke - it's the dif between $28.50 and almost $180!

 

The system needs to be changed so that family docs are fairly renumerated, but also so that they take the time on the cases that need it! But to raise the A007 general assessment fee (as they always do) is not the solution: there'd still be unscrupulous docs taking 5 min with everyone making huge amounts of money, and the rest would only be left with something decent.

[Guest everyoneloveschem]

I am also not a med student :\ . I do work at an office with 9 GP's and it has been a very informative experience.

 

Recently at one of our admin meetings, the doctor who brings us the physician's concerns, told us that they are considering moving to a new pay system, a non-fee per service system. He explained that they will think on it for a while, as there are pros and cons and that if they did decide to change, it would take ~1year. What sounds great though, is that since it is not fee for service, a Dr. could actually spend enough time with each problem, or see multiple problems at one visit (as many older, or more ill patients need). The scary thing is that in return the Dr's need to make sure the patients don't see other Dr's, so they would need to sign a contract of sorts (plus the Dr's would work a half-day on the weekend, and be on call some nights). It is interesting.

 

On another note, when I was seeing my own GP, we were chatting about the future of family medicine, and she mentioned something similar sounding to what the Dr at my work mentioned, but that Dr's would only get ~120/year for a patient, regardless of how many times you saw them, so that after 4 normal visits or 2 normal visits and a physical you would no longer be making money from them. She said it is not mandatory, but around 4% of GPs have signed on already. I'm not sure if these two are the same idea, or two similar but different ideas. My GP mentioned that in Ireland they do the set amount/patient/year thing, but the Dr's get $750/year/patient, which is significantly more.

 

One last thing. If you go to the CMA website under the student part, they have all sorts of stats there, like average incomes for Dr's across Canada by specialty. GPs average $196k, specialist, way more (and isn't the overlead less?).

 

Something is going to have to be done. If I did (ever - SIGH) get in to Med SChool I would consider FM, but only if the future looked good/stable.

[Guest turtle]

Recently at one of our admin meetings, the doctor who brings us the physician's concerns, told us that they are considering moving to a new pay system, a non-fee per service system.

 

This is actually the case...primary health care reform is under way, though it is going very slowly, supposedly due to difficulties in convincing doctors to sign up. To learn more about it go here: Ontario Family Health Network

 

I should add that changing over to this new systems is not mandatory, docs are just being encouraged to volunteer.

[Guest strider2004]

For information:

A001 - minor assessment $17- ie. monitoring blood pressure, takes 5 min

A007 - intermediate assessment $28- ie. by the way doc, my knee has been hurting and I have this sore in my mouth, closer to 15 min

A003(I think) - general assessment $54 - ie. annual physical, should take 30 min

 

Most FPs have a split between A001s and A007s plus a couple of general assessments each day. Docs can also opt to do a consultation instead of an assessment. They log the start and stop time of the consultation and it's about $120/hr.

 

For specialists, they bill about $120/consultation and $54 per repeat consultation on the same patient. Procedural specialties make more money. It's not the consultant fee that does it. For example, rheumatologists make about as much as family docs but the more procedure based specialists (gastro, cardio, resp) rake it in. This doesn't count surgery. They work hard for their money.

[Guest macMDstudent]

I have had some very detailed discussions with some family physicians about the new Family Health Network system, both with some in one now and some still considering the pros and cons of joining.

 

The ones I know that have joined are very happy with their decision to do so. They have seen their income increase by about 30 to 40% since switching are are now netting (after all overhead has been paid) in excess of $20,000 per month for a practice of about 2,000 rostered patients. This means an annual income of about $240,000. The doctors I have met are in their office for about three full days (9 a.m.-5 p.m.) and one half day (9 a.m.-noon) each week. They also do about one evening clinic every two weeks and one overnight shift admitting patients at the local hospital every third week or so. They estimate they work 35-60 hours per week, depending on what shifts that have to do, but most of the time it is about the "average" work week of 40 hours.

 

The lifestyle benefits of this new system are great as well. They can now take paid vacations because they get paid monthly based on how many patients are on their "roster" not on a fee-for-service basis. While they are away, the other doctors in the Family Health Network (FHN) will see their patients. The doctors decide themselves how much vacation they each will take each year and work out coverage for their patients within the FHN. Most doctors I have run into are taking 6-8 weeks vacation per year now with no income loss while away. This is a big advantage for the doctors in this system.

 

They also get bonuses for doing things they were already doing, like having a high percentage of their female adult patients get Pap's done each year or having a high percentage of their infant patients vaccinated. Extra work they choose to do, like emergency or nursing home work, is still fee for service, paid out on top of their monthly fees they receive for their office roster of patients. So those that want to work harder can still be rewarded for it.

 

They have told me they feel free to practice medicine they way they were trained to, and don't feel as constrained by the "grind" of pushing patients through as when they were fee for service. I have heard them say they have a renewed positive outlook on their practice and feel valued again by the 'system.' They also feel that their patients really do have better access to primary care anytime, either through themself or one of their collegues who is on-call for the FHN so that their patients don't have to go to walk-in-clinics after hours.

[Guest peachy]

Thanks, macMDstudent, that's really interesting. The official site (not surprisingly) discusses the Networks in glowing terms as well. Are there any cons? Why haven't more physicians switched over?

[Guest macMDstudent]

I think the reason more family physicians haven't joined can be explained by a few main points.

 

The biggest one is fear of the unknown. Any change can be perceived as risky and a lot of physicians are understandably nervous about completely changing the way they are compensated. After all, we are talking about their livlihood here and of course anybody with with many financial obligations to support their families, their own personal lifestyles, and their office overhead (most family physician groups have many employees) would be reluctant to change everything just because the government says its a good thing! They want have some more reassurance than that, because don't forget doctors that have been around for awhile are somewhat leary about the Ministry of Health after they have seen the system crumble around them.

 

I think that some also fear a loss of autonomy and control over their own working hours and conditions. In other words, if they sign up to be a FHN doctor, sooner or later the Ministry will tell them what hours to work, who their patients are, what office space they have to work in, and who they must work with. As it is now, these issues are just not true, as the doctors I have seen that have joined all still work in the same office, with the same staff (that they now pay better and are happier too) and work out their hours within their own group of physicians. But could it happen? Who knows.

 

The other big reason I have heard is that after looking at the fine details of the FHN, many doctors don't feel it will suit their practice for a particular reason. Doctors who do a very high volume (i.e. seeing more than 50 patients a day for 4 or five days a week) probably will lose income. Family docs who work very part time and have small practices also problably would not gain anything by switching either. Physicians who have a focused area that they concentrate on under the scope of family medicine may lose income as well. For example, someone who does nearly all obstetrics on referral from other family physicians will probably not stand to gain anything.

 

Certainly it will take a while and the FHN system as I have had it explained to me is meant to reward the average family physician for a comprehensive practice. Physicians whose practices don't match up with that concept probably won't benefit.

 

What I have heard doctors talking about in the lounge at the hospital is they don't want to see their collegues get a 30%-40% pay raise and they don't just because they are unwilling to change with the times. My feeling is that more physicians will start to join up as they hear their collegues adapting to it.

[Guest UWOMED2005]

The family doctors I am currently working with are very, very, very much against the new Family Health Networks

 

Check the following Links:

 

www.cofp.com/media/sep03_02medpost.asp

 

www.cofp.com/media/may13_03.asp

 

www.cofp.com/bulletins/jun16_03.asp

 

www.cofp.com/pdf/Brian_Sh...y18-03.pdf

 

In particular, the last link is to an analysis done by a labour lawyer retained by the Coalition of Family Physicians to assess the Family Health Group contracts. It finds a number of legal pitfalls with signing up for a FHG.

 

My impression is that the Family Health Groups are at best an attempt by the government to rearrange the Status quo to make it appear that they are dealing with the current family medicine crisis in Ontario without spending any more resources. . . at worst they are an attempt by the government to gain more control over family physicians in the future.

[Guest UWOMED2005]

Here's an easier to read summary of that Shell report:

 

www.cofp.com/media/jul23_03bshell.asp

 

And I quote:

 

"The patient disclosure issues alone are so substantial, Mr. Shell warned, that it would be "foolhardy for family physicians to ignore the concerns and expose themselves to legal challenges, professional humiliation, disputes with their FHG partners and colleagues, and complaints directed at them by their own patients and by the additional regulators." "

[Guest macMDstudent]

Keep in mind Family Health Networks and Family Health Groups are not the same thing and are not interchangable terms. I am not sure of the exact differences, but I think the basic difference is that in the Family Health Network the main method of compensation is the annual fee per patient (capitation) whereas Family Health Group doctors also roster patients but are still essentially fee-for-service.

 

I have also heard the COFP referred to as a "fringe" group of a loud but small minority who have a political axe to grind with the OMA and the government. The family physicians I have come in to contact with don't give the COFP much respect or credibility and refer to the OMA and CMA for guidance in legal/political matters. The Family Health Network Plan was created by a joint effort of the OMA and the Ontario Ministry of Health and Long Term Care, trying to account for the practice style of the majority of family physicians in Ontario as billing records indicated over the past years and in consultation with a large number of OMA members. I attended a very interesting talk by the OMA president on this very issue earlier this year.

 

It is easy to see how political lines are being drawn in the sand and sides are being taken within the profession over the issue of primary care reform. Obviously, there is no quick and easy answer.

[Guest UWOMED2005]

Sounds like you've done more research into this than me - I just got that link from one of the docs at the hospital I'm currently doing a placement at.

 

Still, I must admit that I am dubious about these Family Health Networks - I need to do some research.

[Guest Ian Wong]

Great discussion! There's been lots of interesting points made in this thread. I have to first state that I don't have any first-hand experience with this new model. I guess the major thing is to tease apart all the various aspects of this new model because several of these aspects could perhaps be adaptable to the current Fee-For-Service model instead of trying to replace/supplant Fee-For-Service by the new Family Health Network model.

They have seen their income increase by about 30 to 40% since switching are are now netting (after all overhead has been paid) in excess of $20,000 per month for a practice of about 2,000 rostered patients. They estimate they work 35-60 hours per week, depending on what shifts that have to do, but most of the time it is about the "average" work week of 40 hours.

The thing I don't get is, what has changed under this system to allow doctors to spend the same number of hours working as before, while making more money? Are there now nurses/PT's/OT's, etc grouped into this FHN who are contributing to the family doctor's productivity? It just doesn't seem fathomable to me that you can work less and make more money, because the limiting reagent (a doctor spending time with his/her patient) is the same under both the FFS and FHM models.

They can now take paid vacations because they get paid monthly based on how many patients are on their "roster" not on a fee-for-service basis. While they are away, the other doctors in the Family Health Network (FHN) will see their patients.

The thing is, this was always possible in a group practice under the FFS model. Many family doctors work in group practices and share call, and tweak their schedules between them to optimize their time off. When you take time off under FHN, you still get paid because your group partner is seeing your patients for you. You will "pay that debt back" when you are conversely covering your partner's patients during his/her vacation. This is no different than under the current FFS model where you take time off, and your group buddy takes in your patients (thereby doing more work while you are away, because his/her patient base has just effectively doubled).

They also get bonuses for doing things they were already doing, like having a high percentage of their female adult patients get Pap's done each year or having a high percentage of their infant patients vaccinated.

The thing is, why is important preventative health stuff like this being rewarded by bonuses in the FHN network, but not in the FFS model? It would be very trivial to add an additional billing code for doing these above things, and adding this financial incentive to the FFS model (and not just the FHN model), would motivate busy doctors to spend that extra time counselling their patients.

 

I guess the only reason I see things this way is that FFS titrates your income to your workload. If you work harder, you get paid more. Under a salaried system, it's very easy for your salary to stay static while your workload continues to increase annually (which will continue to be the case for most Canadian doctors as we dive headfirst into this ever-worsening doctors shortage), or alternately, for doctors to try to work as little as possible while maintaining their static income.

 

Because switching to a salaried system basically leaves you at the mercy of your employer, I've heard of many doctors doing "shadow-billing", which is where they still take the time to log and bill for every patient and procedure, in an attempt to prove their actual worth. This is hugely inefficient, but it definitely happens.

 

Here's an example. Say Joe Doctor is a specialist currently making $200,000 under the FFS model. He becomes a salaried employee of the province, and is salaried at $200,000. Good deal, because now he saves all that extra time spent accounting for his billings for each of his patients and procedures. He's really happy for that first year, because now he doesn't waste all that extra time, nor does he feel pressured to rush through his patients each day.

 

Of course, that next year, Joe Doctor's workload increases, either due to an increasing patient load, or due to the retirement of someone else in his group practice (both pretty likely given the aging of our population). Now, Joe Doctor is working longer and harder, and would ordinarily now be making $250,000 under FFS, but is still making $200,000 because he's salaried.

 

So, he goes back to accounting and logging all his billings, so that the following year, when he renegotiates his salary contract, he can tell the government that his salary should be increased significantly, or at the very least, held constant, because currently he is doing a $250,000 job for $200,000. So, even though he's salaried, he still ends up spending all that extra time logging his billings, which neatly defeats the whole purpose of being salaried from a physician's perspective...

 

Ian

 

 

Edited to add:

 

macMDstudent,

 

You've got way more experience running an office than I do (seeing as I have exactly none!), and my comments weren't so much directed at your statements as to the general audience. I know that your background has certainly got you covered for a lot of what I mentioned (I'm sure you've either been in a group practice before, or otherwise have significant experience with them, as well as with the FFS payment scheme).

[Guest UWOMED2005]

I accidentally brought up the subject of Family Health Networks and Family Health Groups in the Doctor's lounge. Yep, they're very, very opposed to the idea of signing a contract with the government that could bind you. One of them had COFP membership renewal form with him when he walked in, coincidentally.

 

Guess we know different family docs, eh?

 

And one of the docs was saying Capitation would pay $96/patient for the whole year?

[Guest Macmeds06]

The thing I don't get is, what has changed under this system to allow doctors to spend the same number of hours working as before, while making more money? Are there now nurses/PT's/OT's, etc grouped into this FHN who are contributing to the family doctor's productivity? It just doesn't seem fathomable to me that you can work less and make more money, because the limiting reagent (a doctor spending time with his/her patient) is the same under both the FFS and FHM models.

 

Hi Ian,

 

Is it not possible that the cost savings are at the provincial level, and some of these savings "trickle down" to the MDs, resulting in an increased salary?

 

From a public health perspective, if patients have quicker access to their Family doctors (or one of a group partner)through a FHN, many conditions may be treated effectively before they spiral into complex and more critical conditions. This alone would translate into fewer 911 calls, fewer emergency room visits, a different batch of medications, fewer diagnostic tests- all of which would lessen the provincial funding burden.

 

Am I using flawed logic or is it possible that the province took this into consideration when deciding to compensate FHN doctors with a greater salary?

[Guest everyoneloveschem]

What I don't get is why GPs make so much less than specialists in the first place??

 

From watching our doctors, it seems that paying the GPs so little is just an incentive for them to find other ways of earning money, like consulting, working for old age homes, or after hour clinics, etc. Why not just pay them more (or give them benefits/salary) and then hopefully they would work more hours as GPs and then take on more pts??